JOBS for LIFETM Applicant Background Information
Name: Male Female (circle one)
Address:
City: State: Zip Code:
Phone: Email:
Social Security #: Date of Birth:
Ethnicity: Church Affiliation (if any):
Are you a United States Citizen? Yes No
If not, can you provide residency papers? Yes No
Will you be able to provide the following forms?
- Birth Certificate Yes No
- US Social Security Card Yes No
- Driver’s License Yes No or Non-Driver ID Yes No
Please list any physical handicaps or other special needs.
Educational Background Information:
Circle the highest grade achieved 4 5 6 7 8 9 10 11 12/GED Vocational Training College
Name of High School City/State
Enrolled from Year to Year Graduated? Yes No
If you have received education training beyond High School or GED level, complete the following:
What is the name of the college or vocational training facility you attended (use additional sheets if necessary)?
Training Facility/ College Name City, State
Enrolled from To
Did you receive a certificate or diploma from this college or training facility? Yes No
If yes, what training/degree did you receive?
Previous Work Experience:
List your last four employers, starting with your most recent or current employer. Include military and volunteer experience. Be as complete as possible.
Business Name: Address:
Phone:
Start Date: End Date:
What is/was your job title?
What are/were your duties?
Who is/was your supervisor?
If you are no longer employed here, why did you leave?
Business Name: Address:
Phone:
Start Date: End Date:
What was your job title?
What were your duties?
Who was your supervisor?
Why did you leave?
Business Name: Address:
Phone:
Start Date: End Date:
What was your job title?
What were your duties?
Who was your supervisor?
Why did you leave?
Business Name: Address:
Phone:
Start Date: End Date:
What was your job title?
What were your duties?
Who was your supervisor?
Why did you leave?
Security:
Have you ever been convicted of a felony and/or served time in the past? Yes No
If yes, please describe below. Note: Providing this information will not disqualify a person from becoming a Jobs For LifeTM participant.
Incident | Year | City, State | Charge & Release Date |
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Are you willing to take a drug test? Yes No (answering “No” will not disqualify a person from becoming a Jobs for Life TM participant.
Current Employment Status:
Check all that apply:
Unemployed Full-time job Part-time job Public welfare recipient _____
If employed, name of employer: Current wage: (optional)
Current Marital/ Family/Housing Status:
Married Single Divorced Separated Widowed
Do you have children? Yes No If yes, how many?
Housing Arrangements: Rent Apartment Rent House Own Home Homeless Other (If other, please explain .)
Jobs For Life TM Training Information:
Will you need child care during your Jobs for Life TM training? Yes No
Will you need transportation during your Jobs for Life TM training? Yes No
What is your reason for taking Jobs for Life TM training?
What is your present job objective?
Other hobbies and interests:
JfL Applicant Signature Date
This page for referring church/organization/individual use only (if no referral, leave blank):
Church/Organization/Individual Name:
Address:
City: State: Zip Code:
Phone/Fax: Email:
Pastor/Director’s Name: Email:
Evaluation Checklist:
Name of person completing evaluation: Phone:
Position at referring organization: Email:
Relationship to applicant: How long have you known this applicant?
In your opinion, how serious is this applicant about completing the training and establishing a career?
How do you assess the applicant’s character and moral integrity?
Will additional training benefit the applicant? Adult Literacy GED Computer Skills Other
Please describe:
What other needs does the applicant have (e.g. substance abuse counseling, health problems, English language training, etc.)?
Do you recommend this applicant for program participation?
If so, why?
Jobs for Life TM Lead Champion:
Champion’s Name (if assigned): Phone:
Address:
City: State: Zip Code:
Email: Fax:
Signature Date
(REVISED 12_2005)
Mail completed form to: PO Box 14667, Greensboro, NC 27415
For more information call : 336-274-4692, visit www.pdyfinc.com or email mtallen@pdyfinc.com